Local-Regional Anesthesia Better Than General for EVAR

Download this article's Factoid (PDF & PPT for Gold Subscribers)

Patients undergoing endovascular aortic aneurysm repair (EVAR) experience less pulmonary morbidity and shorter hospital stay if they are given spinal or local anesthesia as opposed to general anesthesia, researchers conclude in a study published online July 1, 2011, ahead of print in the Journal of Vascular Surgery.

Investigators led by Matthew S. Edwards, MD, of Wake Forest University School of Medicine (Winston-Salem, NC), analyzed 6,009 elective EVAR procedures performed between 2005 and 2008 included in the American College of Surgeons National Surgical Quality Improvement Program database, correlating outcomes with the type of anesthesia administered.

General anesthesia was used in 81% of cases, spinal anesthesia in 7%, epidural anesthesia in 5.5%, and local/with or without monitored anesthetic care (MAC) in 6.5%.

The 3 major outcomes analyzed included morbidity, mortality, and length of stay.

Anesthesia Type Linked with Morbidity, Length of Stay

Overall, defined morbidity (categories included wound, pulmonary, renal, venous thromboembolic, CV, operative, and septic) occurred in 11% of patients. The mean length of stay was 2.8 ± 4.3 days. At 30 days, the mortality rate was 1.1%.

There was no association between anesthesia type and mortality. However, both morbidity and length of stay varied by anesthesia type. In multivariable analysis, use of general anesthesia was associated with increased pulmonary morbidity compared with spinal (OR 4.0; 95% CI 1.3-12.5; P = 0.020) and local/MAC anesthesia (OR 2.6; 95% CI 1.0-6.4; P = 0 .041). Use of general anesthesia also prolonged length of stay, with a 10% increase for general anesthesia vs. spinal (P = 0.001) and a 20% increase for general anesthesia vs. local/MAC (P < 0.001). These differences were not observed for general vs. epidural anesthesia.

Importantly, compared with general anesthesia, use of spinal or local/MAC anesthesia also was associated with a 60% to 75% decrease in the odds of postoperative pulmonary complications, including pneumonia and failure to wean from the ventilator within 48 hours of surgery (table 1).

Table 1. Pulmonary Complications by Anesthesia Type

“These complications obviously increase patient discomfort and commonly require admission to the ICU or extension of the ICU stay,” the authors write. “Given the high estimated cost of such nosocomial pneumonias (> $12,000 per occurrence) and the potential savings of the observed decreases in [length of stay], the significance of these data to contemporary American health care is obvious.”

The researchers add that despite the fact that their study is a secondary analysis of a database and subject to potential confounders, they believe the data “support an increase in the use of local anesthesia/MAC or spinal anesthesia in EVAR patients suitable for such anesthetic approaches to reduce pulmonary morbidity and length of stay.”

Anesthesia Choice Has Major Cost Impact

In a telephone interview with TCTMD, William A. Gray, MD, of Columbia University Medical Center (New York, NY), said although it is not a surprise that general anesthesia had more postoperative problems, it is useful to have the supporting data.

“This shows we should do whatever we can procedurally to enable MAC as the primary mode of anesthesia because of the issues shown in this study, specifically the association with pulmonary morbidity,” he said.

Furthermore, Dr. Gray said that while the authors are correct about the high cost of pulmonary complications, another obvious take-away message is that general anesthesia itself is expensive, as is extended hospital stay.

“Strictly from a cost-effectiveness standpoint, you are going to save money on anesthesia, hospital stay, and also complications. This paper will go a long way hopefully in educating and changing practice patterns,” he said. “It would be great to do a follow-up paper in 5 years to see what has happened in terms of distribution of anesthetic choices for EVAR.”

 

---

Source:
Edwards MS, Andrews JS, Edwards AF, et al. Results of endovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg. 2011;Epub ahead of print.

 

 

Related Stories:

• Study Raises Concerns About Noncompliance with EVAR Guidelines for AAA
• EVAR, Surgery Show Equivalent Long-term Survival in Less Risky AAA Patients
• Women Face More Complications After Percutaneous AAA Repair